Like so many other areas in hospice, the general inpatient level of care
(GIP) is coming under increased scrutiny by the Department of Health and Human
Services (HHS), Office of the Inspector General (OIG) and the Centers for
Medicare and Medicaid Services (CMS). The OIG is currently conducting a series
of studies and audits on the GIP level of care. Although the OIG’s most recent reportMedicare Hospice:
Use of General Inpatient Care, published May 3, 2013 provided no
recommendations for hospices in terms of change in practice, it is a precursor
for an upcoming audit report, which will be based on a medical review of GIP
charts.

The May 3rd report noted that 33% of GIP stays in 2011 were longer than 5 days
and 11% were longer than 10 days. According to the report, the average stay was
6.1 days in an inpatient unit, 4.1 days in a hospital, and 4.8 days in a skilled
nursing facility. Interestingly, they also focused on underutilization, noting that 25% of hospice in 2011 provided
little or no GIP, continuous home care, or respite care and suggested that CMS focus on
whether hospices are providing access to all 4 required levels of care. In addition to
this report, the 2012
OIG Work Plan indicated that they would focus on acute inpatient transfers
to inpatient hospice care at the GIP level.

Implications for Providers

So what does this mean for you as a provider? It seems that if the OIG is
“concerned” about the provision of GIP, we in the hospice industry should be
concerned as well.

In our work with clients, Weatherbee sees a wide
divergence in both the utilization of GIP and the conditions under which GIP is
provided. In many instances, clinical record audits reveal that
the patient is eligible for GIP (e.g., the patient's condition warrants the higher level of care as evidenced by pain or symptom management needs that cannot be met in the home setting); however, the documentation does not
support payment for the higher level of care (e.g., the documentation does not evidence that a higher level of care was actually being provided).

We also have encountered hospice programs in highly saturated markets that are unable to obtain contracts with local hospitals and SNFs and, therefore, do not
offer the GIP level of care. This places the hospice at risk of underutilization and its patients at risk of negative outcomes. Given that GIP is a
requirement of the Medicare Hospice Benefit, its provision is not optional.

Common practices that we believe contribute to some of the
current problems with GIP utilization include:

Ineffective or untimely discharge planning (e.g., patients remaining on GIP for a prolonged period while waiting for a SNF bed to become available)

Automatically admitting dying patients to the higher level of care regardless of their actual clinical needs

Automatically admitting patients from an acute care hospital to the GIP level of care before going home (i.e., using GIP as a "step-down" or transitional level of care)

Inadequate documentation evidencing the need for GIP

Lack of involvement by the hospice team when the
patient is placed on GIP in the SNF setting

Inappropriately utilizing GIP for caregiver breakdown or
respite

What Hospices Need to Know

1. What
is GIP?

GIP is intended to
be short-term care provided in an inpatient facility for the purpose of
providing pain control or other acute symptom management that cannot be
feasibly provided in other settings.

2. What
are some of the criteria for admission to GIP?

Evidence of a precipitating event and
interventions that have been attempted to manage the pain/symptoms

Documentation of the patient's skilled need and why there
is no other appropriate setting in which to manage them

Physician's order

3. What
are some of the symptoms that would qualify for GIP?

Uncontrolled
pain requiring frequent medication adjustment, aggressive treatment, or
complicated technical delivery of medication which requires an RN to do the
calibration etc.

Intractable
nausea and vomiting

Unmanageable
respiratory distress

Seizures

Hemorrhage

Pathological fractures

Severe agitated
delirium

Wounds requiring
complex and/or frequent (skilled) dressing changes

Imminent death if skilled needs are present

Caregiver
breakdown only if the patient has unmet skilled needs

4. What
should hospices document?

Changes in the plan of care that reflect
the change in the patient’s condition and the new patient/family goals and
interventions

All of the symptoms being managed, how they are
being managed, and with what frequency

The patient’s response to interventions

Evidence of patient/family education

Evidence of discharge planning to return the
patient to a lower level of care

Evidence of coordination of care between the
hospice team and the staff at the facility providing the care

Documentation that shows that the hospice has
remained responsible for the professional management of the patient’s care

Ongoing documentation throughout each 8-hour
shift. Again, the documentation should
be as thorough and specific as possible noting the frequency of the
interventions, the response to interventions, and any changes that have occurred
in the patient’s condition.

Don’t be afraid to admit patients
to the GIP level of care, just make certain the patient’s care needs justify the
higher level of care and that the clinical record supports the team’s decision to
provide it.

The Takeaway

Patients are entitled, under their
Medicare Hospice Benefit, to receive the GIP level of care. Hospice providers need to
be prepared to offer this care to their patients. However, they need to do so
in such a way that they adhere to the current guidelines for the provision of
this level of care. Periodic staff education and the development of internal
policies and procedures regarding the use of GIP are measures that can offer
hospice programs a higher comfort level as scrutiny increases. Periodic pre-billing audits are also recommended. These audits should evaluate whether the higher level of care was both needed by the patient and provided by the hospice.